Application for Certificate
Note: Please print or type your legal name as you would like it to appear on your certificate. This form should be printed,
signed, and submitted to your advisor. If you want your legal name changed on your record, you must complete the name
change form available at
Legal Name Clarion ID
Please indicate the address you would like your certificate mailed to:
Street Address
City, State, Zip Cell/Day Phone
Name of program
(i.e. Public Relations, Pre-MBA, etc.) * University approved certificates that meet PASSHE guidelines.
Please specify the semester/session and year that you plan to complete all requirements for your certificate:
Semester/Term (i.e. Fall, Winter Intersession, Spring, Summer 1, Summer 2, Summer 3)
Required Signatures:
In signing this form, I certify that I have reviewed my Degree Audit and I understand that I will not complete the certificate
on the date specified unless all requirements are met by the official end of that semester. Failure to do so, will result in
updating my completion date to the term/year the incomplete work and/or this application are completed. Please see
graduation and degree conferral policy for more information:
Student Signature Date
Faculty: Before signing this application, please review the student’s Degree Audit and make sure all requirements will be
satisfied. If not, please DO NOT sign the application until all requirements are met or the appropriate waive/substitution
request(s) have been submitted.
Advisor Date
Department Chair Date
College Dean Date
College Deanplease forward this application to the Registrar’s Office after the student has successfully completed all
requirements for the certificate for notation of completion on the student’s academic transcript.
Registrar’s OfficeClarion University of Pennsylvania 5/2016